Inside Health

Rikers Suicide Called a Glaring Example of Poor Care

By PAUL von ZIELBAUER

Published: April 4, 2005

It was 2:50 p.m. on July 18, 2004, when David Pennington, a 27-year-old small-time thief in jail on a third-degree burglary charge, was sent from a clinic back to his cell at Rikers Island's largest jail. During the previous three days, jail doctors had received ample evidence showing that Mr. Pennington should not be left alone.

Two days earlier, according to investigators, he had told a social worker at Rikers about two attempts to kill himself, about his psychiatric hospitalizations, about his father, who had killed himself in prison. Near the end, Mr. Pennington, increasingly agitated, had even told a jail doctor that he was hearing voices and was thinking again of killing himself.

Still, Mr. Pennington was sent back from a Rikers mental health clinic to what is called the jail's general population -- Cell 26 in Quad 14 -- without any special instructions to correction officers or medical staff to keep a close eye on him. In fact, state investigators later discovered, Mr. Pennington was returned to his cell after a jail psychiatrist, despite being alerted by another doctor, chose not to examine him.

Six and a half hours later, jail officers heard a commotion outside Cell 26. Inmates were gathered around the locked cell door, yelling for help. The officers rushed over to find Mr. Pennington slumped against the door, hanging from a bedsheet tied to the door's small window. He was brain dead, and three days later, at Elmhurst Hospital Center in Queens, his family had him removed from life support.

For the correction and medical workers at Rikers Island, Mr. Pennington was another entry in the disturbing catalog of suicides inside city jails in recent years.

In the view of state investigators, Mr. Pennington was another casualty of the sometimes deadly mistakes made by the Tennessee company hired to provide health care at Rikers, and to thereby tackle the problem of the growing number of mentally ill inmates who populate the jail, a sprawling complex in the East River.

Over the past four years, in a series of increasingly urgent reports, the New York State Commission of Correction has excoriated the company, Prison Health Services, for mistakes in the care of 23 inmates who died in city and upstate jails. The commission, which is appointed by the governor to oversee jail and prison standards, has repeatedly condemned Prison Health for flouting state medical standards, hiring poorly qualified doctors and nurses and failing to properly treat several of its sickest patients, who eventually committed suicide -- the leading cause of death in American jails.

In its report on Mr. Pennington, made available to the public last week, the commission issued some of its harshest criticism of the company, calling its care of Mr. Pennington ''flagrantly inadequate,'' and again asserting that the company was practicing in the state in violation of the law because executives in Tennessee, and not doctors at Rikers Island, were ultimately in charge of dispensing care.

In a letter accompanying the report, the commission also criticized the city's Department of Health and Mental Hygiene, which monitors Prison Health's work at Rikers, for excusing the company's errors and for what it said is the company's continuing improper operations in the state.

State law requires that a company dispensing medical services for a profit must be owned and controlled by doctors, to keep business interests from affecting medical decisions. Prison Health Services, a publicly held profit-making company that the city pays $100 million a year, says it subcontracts its medical services at Rikers to a small corporation run by a doctor who is also its regional medical director. The state commission, in its letter to the city's health department, said that the arrangement ''begs credulity'' and ''only raises further questions'' about the legality of the company's operation here.

City health officials have said that Prison Health does a satisfactory job and performs its work legally. In a letter to the commission in January, James L. Capoziello, the health department's deputy commissioner in charge of monitoring jail health care, disputed the commission's conclusion that Mr. Pennington received poor or improper care.

A department spokesman declined to comment last week on the commission's findings in Mr. Pennington's death or the letter that accompanied the report. Prison Health, through a spokeswoman, also declined to comment on Mr. Pennington's treatment but said the company's work in New York complied with state laws.

But officials with the city's Board of Correction, a watchdog agency that monitors the safety of the city's jails and sets minimum health standards, said that the lack of care Prison Health gave Mr. Pennington before his death was particularly troubling given his mental-health history, his report that his father had killed himself in prison and his own increasingly suicidal behavior.

In an interview on Friday, Cathy Potler, the board's deputy executive director, said, ''The question is, what happened between the time he was noted to be hallucinating and suicidal and the time he was found unresponsive in his cell?''